In Samuel Shem’s seminal 1978 novel about medical internship, The House of God, the protagonist calls patients “GOMERs,” an abbreviation for “Get Out of My Emergency Room.” This term of “endearment” is the tip of the iceberg for a particular brand of dark humor medical providers like doctors and nurses often use, sometimes referred to as medical “gallows” humor.

This humor is not your warm, fuzzy Patch Adams and clowns in the childhood cancer ward type of humor. This is Joan Rivers meets death metal meets hydrochloric acid humor.

During the treacherous process of transformation from medical student to doctor, I noticed that my sense of humor changed in these embittered, bizarre ways. There is little left to the imagination after medical school, between cutting through cadavers, then live people, poking and prodding strangers in their most vulnerable states. What would be deemed inappropriate, even criminal, in another context becomes professional and caring in the hospital. But sometimes the contrasts and discrepancies that arise in the process lead to situations that one might view with horror, or with humor, or an uneasy admixture of both.

Psychiatrist George Vaillant cited humor as one of the most mature ego defense mechanisms—mature, at least, relative to more primitive defenses like anger, projection, denial and the like. But the content of humor is highly subjective, and oftentimes the more regressed and obnoxious it is, the more “immature” if you will, the funnier for some, the more offensive for others. Gallows humor skirts this line in a unique way.

Sigmund Freud mentioned gallows humor in his 1927 essay “Humour” as a way for the ego to transform suffering and trauma (“the provocations of reality”) into something “to gain pleasure” instead. Antonin Orbdlik, a Czech sociologist who lived under Nazi occupation, notes in his 1942 essay “’Gallows Humor’—A Sociological Phenomenon” that oppressed victims during this occupation used this humor to “bolster the resistance of the victims and…undermine the morale of the oppressors.” By making light of an otherwise dangerous situation, they no longer completely feared their enemy and were able to mock them and feel a sense of control and social empowerment. (One might argue that the controversial movie “The Interview” does the same thing against the toxic regime in North Korea.)

In medicine, extremes of mortality, pain, illness, suffering—the darkest experiences around—confront medical providers. Our empathy is stretched to the breaking point numerous times, all the while under intense pressure to perform perfectly, within cost and time constraints, and sometimes without sleep. We are trained to remain calm in the face of blood, piss, vomit, shit, agitation, shrieking pain, and still administer tests and procedures and medications flawlessly, lest we cause more suffering and death. We must also simultaneously cater to the patient’s emotions, as human beings going through illness and stress, comfort them even if they are driven to occasionally abuse us in the throes of their understandable agony.

So as human beings ourselves pushed to the highest standards of responsibility, doctors and nurses often rely on this gallows humor, a pressure valve for what we face. I’ve heard similar types of humor expressed by members of other high-pressure fields that confront daily mortality, like the military or the police. According to Dartmouth Medicine Magazine, a 2005 survey of 608 paramedic and emergency medical service (EMS) professionals by Victoria Corum, a flight paramedic, found that nearly 90% admitted to “using dark humor.” Other coping mechanisms like talking with colleagues and family and friends ranked a distant second and third at 37% and 35% respectively. In a 2012 Mayo Clinic Proceedings article, Lewis Cohen MD discussed a survey of 633 palliative care providers where about 72% had heard darkly humorous comments about them like “Dr. Death” mainly from other physicians (59%) and health care professionals (49%), but also from family members and friends as well, and even patients and their companions (21-31%).

Yet, people outside these fields are sometimes horrified, angered when they hear some of these jokes, particularly if directed at patients. They, understandably, see the jokes as dehumanizing, objectifying, belittling, particularly of patients who are already felt to be in a vulnerable, dehumanized state. I have admittedly been caught off guard by lay people chiding me for incidental comments I’ve written or spoken, that made me step back and wonder what has changed in me, and is it all bad? Have I become a callous person? Or am I more in touch with reality than people who haven’t slogged through the same trenches?

Katherine Watson, a medical ethics professor and lawyer at Northwestern University, wrote a detailed and enlightening treatise on the use of gallows humor in medicine in The Hastings Center Report in 2011. In it, she cites some of the power dynamics that come into play with this type of humor, where patients who make doctors feel helpless become the butt of jokes. In particular, difficult or noncompliant patients are made fun of those most, because they are an easy target for the futility doctors feel about their control of some illnesses.

For example, when I worked on an inpatient psychiatric unit, several patients were frustrating repeat visitors, due to poor adherence with medications, severe illness, entrenched personality disorder traits, and/or other difficult socioeconomic circumstances (homelessness, drug abuse, etc.) While some patients would improve and get discharged quickly, others would have a tough time and a prolonged stay, due to refusing medications, repeatedly threatening to harm themselves or threatening staff, being combative, cursing psychotically, and more. Despite claims (and sometimes realities) that patients feel mistreated on psychiatric units, oftentimes overworked clinicians themselves also can feel used and abused. So sometimes, during our rounds and internal meetings, the staff would often crack sarcastic comments about “frequent fliers,” and more.

Does this type of humor help or harm the doctor-patient relationship? On the minus side, providers might fall into a cynical mindset, where the patient becomes at best annoying and at worst a punching bag or mortal enemy. Our capacity for empathy might deteriorate when we get into the habit of mocking suffering on a routine basis; we may even miss actual serious clinical findings when we stop believing our patients because we assume they are exaggerating or manipulating us, like the boy who cried wolf.

I will always remember one particular patient who had the typical “difficult” patient profile of multiple hospital visits asking for various pain or anxiety medications for vague somatic complaints. This time the already obese patient complained again of not feeling right, and swelling breasts, which seemed stereotypically hysterical or attention-seeking. Our first instinct was to roll our eyes and laugh about her symptoms, to think GOMER all the way. But thankfully, we still ran routine tests, and it turned out that the patient had a lung tumor releasing hormones that indeed caused breast swelling. This time, sadly, she had very real cancer.

On the positive side, our morbid sense of humor can promote bonding between team members and help relieve stress when faced with patients who are genuinely tough to handle or get through situations that are unspeakably tragic. Watson’s article opens with an exhausted emergency room team who ordered a pizza, and the delivery boy ended up becoming their trauma patient after he was robbed and shot. The patient died; faced with this horrible set of circumstances, they decide afterwards to joke about how much to tip the poor victim, and they ate the pizza that was found at the scene. While one might initially think, how cruel to joke in such a circumstance, one might also think, what else could this team do to push through a devastating, guilt-ridden situation? Watson concludes that the joke remained “ethical” because no direct harm was done to the patient (it would of course be different to joke in front of family members or patients directly), and perhaps, it even helped the doctors remain sane in the face of horror.

So when doctors and nurses decide to partake in their own taboo humor, is it such a jawdroppingly bad thing to do? Are patients so sacred in their vulnerability that any mockery of their weakness or illness feels like a breach, an act of bullying or even abuse? Or is it the opposite; do the providers feel like the bullied victims in this era of malpractice and managed care and patient satisfaction scores, and their mockery is a form of peaceful rebellion, of civil liberty against the hegemony of the defiant, entitled patient? As Watson notes, the power dynamics are constantly in flux behind the scenes of the doctor-patient relationship, and imbue this humor with varying nuances accordingly.

I would say that doctors and nurses and other medical professionals have earned the right and should have the freedom to laugh about anything, even death and illness. They should watch out for signs of burnout and seek other sources of help accordingly. And they should try as much as possible to crack the jokes behind closed doors. But if you as a patient happen to hear one slip out, instead of righteous anger, try to think about where it comes from. Clinicians feel helpless too sometimes, and humor is the best way for them to stay sane.

"Are patients so sacred in their vulnerability that any mockery of their weakness or illness feels like a breach, an act of bullying or even abuse?"
"Sacred" used here exaggerates to the point of ridicule the vulnerable state of the patient. Vulnerability is vulnerability, and mockery is mockery: jeering, sneering, derision and contempt. This is directed at patients by the very people in awful authority over them.

"doctors and nurses and other medical professionals have earned the right and should have the freedom to laugh about anything, even death and illness".
Laughing at illness and death is very different from laughing at suffering. Your "difficult patient", at whom you were inclined to roll your eyes and laugh, was manifestly unwell, whether you could find objective signs of this or not. She wouldn't have been repeatedly coming to you for help if she was hale and hearty. Where else was she to go for help?
You found something to justify her last complaint, so she became 'deserving' and you refer to her with a little more kindness (for the sake of appearance?)

It's human nature to laugh at the misfortunes of others (or so I'm told), and it's natural for those in a position of power to condescend to those beneath them. These behaviours in a climate of compassion fatigue explain "gallows humour" in doctors.

Your comments about "patients who make doctors feel helpless" and "the futility doctors feel about their control of some illnesses" are also illuminating. Doctors don't like to question themselves, and certainly don't tolerate the possibility of being questioned by others. Omniscience and omnipotence cannot exist with any possibility of a sense of helplessness or futility.

The culture of the medical profession includes all sorts of nasty things, from mockery of patients to silence around sexual harassment of female practitioners, and a little more real dignity wouldn't go amiss. If the culture accepts the mockery of patients, then doctors will practise mocking their patients. They will call it gallows humour, of course, and claim it as a perquisite.

Your article haunts me. No, you can't minimize this behaviour, nor explain it away as necessary to save your sanity. Doctors don't crack jokes over babies and small children, or over their own friends and relatives - why not? I suggest it's because they do practice empathy and respect - when they feel like it.

The anesthesiologist Ingham was not in an emergency situation. She was simply venting her spleen because she could, and it felt good so she did. She didn't need to bond, nor relieve stress, and in any other field her behaviour would be considered grossly unprofessional. And her behaviour is the norm, I'm led to believe.

The culture of the medical profession has institutionalized dehumanization of patients, and you play along. It doesn't need to be so. I'm sure you can readily see that the offensive behaviour will infect many people who work in the environment, teaching that it's not the done thing to show respect for the patient, except to their face, and then only if you must for some reason. Don't you think this will have an effect on your ability to do your job, which, after all, involves actually hearing patients? You do know, I suppose, that people die, after having gone to the doctor for help, because the doctor doesn't respect them enough to take their complaints seriously?

Why enter the profession if this is your attitude to sick people? Every old man might be someone's beloved father, every old woman someone's mother. Every single person you treat is or was someone's precious child. Who do you think doctors are to demean, ridicule and deride a person at their most vulnerable? But then, everyone is a GOMER until proven otherwise, aren't they?

Are doctors so sacred in their self importance that the rules of basic respect for the individual don't apply to them? I despise you for your inhumanity in acting this way, and in defending the behaviour in yourself and others. This is the sort of behaviour you might expect from street thugs towards their victims.

Hello BC, I see this subject stirs a lot of emotion in you, and I think you're viewing it through a lens of extreme or worst-case scenarios of abuse. I totally agree that there is no excuse for openly nasty, abusive, hostile comments by medical staff either to each other or to patients, even behind their back. Dr. Ingram's comments seem to have fallen in this extreme category (although I don't the entire transcript at hand). I agree that patients always deserve at least bottom-line respect and kindness and concern, as illness and suffering are terrible things to endure. I have always treated my patients accordingly.

However what I am discussing are more grey-zone comments such as behind-the-scenes dark humor or joking, which can be very subjective depending on the context in which it is heard. And are not meant to be frankly abusive and cruel, if it is a joke with actual humor in it. (Ingram's comments were decidedly not funny.)

You make though a good point that maybe any such humor can still be toxic in its own way in the wrong setting or manner, and perhaps contribute to a culture of dehumanization towards the patient. I did cite examples above where exasperation or not listening to patients can be deadly. I did say that caution is warranted. I do think there is a difference between saying something to a person's face or not.

I wanted to bring in a discussion of nuance, that there are two sides to the story, that doctors are human and flawed and may need some way to vent against the pressures they face, and yes, maybe they need to accept a lack of control against those pressures sometimes, and patients who test their limits of empathy.

But I hope you can apply some of your concern about respect and tolerance towards me as well instead of 'despising' me for my supposed 'inhumanity.' I certainly respect and have learned from your opinions.